Schizophrenia: Clinical Course

For a diagnosis of schizophrenia, there is always an active phase in which psychotic symptoms, such as hallucinations, delusions, thought disorder, and bizarre behavior, are observed. It is felt that the onset is often exacerbated by a psychosocial stressor. For some, there is a sudden psychotic break, and this active phase is the first sign of the illness.

Before the active phase there is usually a prodromal phase, although if the active phase lasts longer than six months it is not necessary to identify this phase. In the prodromal phase the person may exhibit impairment of role functioning, social withdrawal, odd behavior, loss of interests, poor personal care, some communication disturbances, bizarre ideation, and perception disturbance. Prognosis is poor if this phase is insidious and takes many years to develop.

After the active phase there is a residual phase, which may look like the prodromal phase. Delusions or hallucinations may be present, coupled with blunted affect and impaired role functioning. The individual does not return to his premorbid level of functioning and usually continues to have chronic symptoms.

Schizophrenia is the most severe of all psychiatric disorders. For many people, schizophrenia is a chronic illness with frequent hospitalizations. The course of the illness varies, however, and a small number of people who suffer from the disorder recover with no residual deficits or stabilize at a lower level of functioning than that at onset.

Though prognosis is guarded, some symptoms suggest a better outcome when present than others; they include acute onset, midlife onset, defined precipitating factors, previously good functioning in work and relationships, no premorbid personality disorder, confusion at onset, and ability to follow a treatment plan. Signs suggesting a poor prognosis are early and insidious onset, history of previous episodes, no definable precipitating factors, withdrawal, inappropriate or shallow affect, schizoid or schizotypal personality disorder, family history of schizophrenia, and problems in following a treatment regimen.

DSM classified the possible clinical course as

1. Continuous when there has been no remission of symptoms during the period of observation

2. Episodic with progressive development of negative symptoms between psychotic episodes

3. Episodic with persistent negative symptoms

4. Episodic with remissions between episodes

5. Partial remission after a single episode

6. Full remission

Depression is common among people with schizophrenia and often follows the disorder’s acute phase. Approximately 2 percent of people with schizophrenia will commit suicide, and another 20 percent will make an attempt, usually in the less active phase or during the onset of the first psychotic episode. In the acute phase, attention must be paid to reports of command hallucinations that call for suicide or homicide. People suffering from catatonic or paranoid types of schizophrenia are more prone to homicide than are those with other types of the illness.